MEDICARE: MR. SADHAN MAHANTA OT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XG0600X	Gerontology Occupational Therapist	5201004910	MI

General Provider Information

NPI Number	:	1417331109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SADHAN MAHANTA OT

Provider Business Mailing Address
First Line	:	45341 SEABROOK DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-3252
Country	:	US
Telephone Number	:	734-656-1547
Fax Number	:	734-621-7053

Provider Business Practice Location Address
First Line	:	45341 SEABROOK DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-3252
Country	:	US
Telephone Number	:	734-656-1547
Fax Number	:	734-621-7053

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	08/19/2016

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